Doctors may agree to patient requests for services to increase patient satisfaction

A team of UC Davis researchers found that people who are the most satisfied with their doctors are more likely to be hospitalized, accumulate more health-care and drug expenditures, and have higher death rates than patients who are less satisfied with their care.

Published today in the Archives of Internal Medicine, the national study is believed to be the first to suggest that an overemphasis on patient satisfaction could have unanticipated adverse effects.

Joshua Fenton

"Patient satisfaction is a widely emphasized indicator of health-care quality, but our study calls into question whether increased patient satisfaction, as currently measured and used, is a wise goal in and of itself," said Joshua Fenton, assistant professor in the UC Davis Department of Family and Community Medicine and lead author of the study.

Prior studies have shown that patient satisfaction strongly correlates with the extent to which physicians fulfill patient expectations, according to Fenton.

"Doctors may order requested tests or treatments to satisfy patients rather than out of medical necessity, which may expose patients to risks without benefits," he said. "A better approach is to explain carefully why a test or treatment isn't needed, but that takes time, which is in short supply during primary-care visits."

Patient-satisfaction surveys are commonly conducted by health systems to evaluate patients' perceptions of their encounters with physicians. The results can be used to establish quality-improvement measures with the hope of strengthening patient loyalty.

Fenton pointed out that because many physicians receive incentive compensation based on patient satisfaction, they may be reluctant to bring up the downsides of requested tests or treatments. Providers who are too concerned with patient satisfaction may also be unwilling to bring up uncomfortable issues such as smoking, substance abuse or mental health, which may then go unaddressed.

In conducting the study, Fenton and his colleagues evaluated data from more than 50,000 adult respondents of the Medical Expenditure Panel Survey, a nationally representative survey of the U.S. population that assesses the use and costs of medical services. Respondents completed questionnaires about their health status and experiences with health care, including how often their health-care providers listened carefully, were respectful and spent enough time with them. Participants also were asked to rate their health care on a scale of 0 to 10. The data were linked to the national death certificate registry.

The study found that patients who were most satisfied had greater chances of being admitted to the hospital and had about 9 percent higher total health-care costs as well as 9 percent higher prescription drug expenditures. Most strikingly, death rates also were higher: For every 100 people who died over an average period of nearly four years in the least satisfied group, about 126 people died in the most satisfied group.

Interestingly, more satisfied patients had better average physical and mental health status at baseline than less satisfied patients. The association between high patient satisfaction and an increased risk of dying was also stronger among healthier patients.

"We therefore think it's unlikely that more satisfied patients are somehow more sick and, in turn, more likely to die," said Fenton, who also noted a definitive cause-and-effect relationship could not be inferred from this study.

The research team will next determine why more satisfied patients tend to be hospitalized more frequently by evaluating the clinical situations that lead to hospitalization for the least and most satisfied patients. They also intend to study why prescription costs are higher in the most satisfied group.

"Patients should be satisfied with their physicians, but ideally it's because their physicians guide them toward the best care and not merely because their physicians provide tests or treatments that may do more harm than good," said Fenton.

Additional study authors were Anthony Jerant, Klea Bertakis and Peter Franks, all of the UC Davis Department of Family and Community Medicine.

The UC Davis Department of Family and Community Medicine provides comprehensive, compassionate and personal care for patients within the context of family and community. The medical team integrates a humanistic approach to treating the "whole person" with evidence-based care. Special areas of faculty research are health-behavior change, physician-patient communication, chronic-illness care, women's health issues, and reducing racial and ethnic health disparities. For information, visit the department's website at www.ucdmc.ucdavis.edu/famcommed/